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Children's Miracle Network Hospitals at CoxHealth

Dedicated to raising funds and awareness for the medical care of children, birth through age 18.

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Application Form

FILL OUT COMPLETELY

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Step 1 of 5

20%

Application Date
MM slash DD slash YYYY
Child’s Name
First Last
DOB
Gender
- Male
- Female
Parent(s) or Guardian(s) Name
First Last
Child’s Address
Street Address City State ZIP Code
County*
Daytime Phone
Evening Phone
Mother’s Cell Phone
Father’s Cell Phone
Email Address
Number of Children in the Home
Ages
Attach Documents (i.e. income verification, appointment confirmation, diagnosis information, etc.)
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, docx, tif, ttf, txt, Max. file size: 2 GB, Max. files: 6.
Max of 6 files accepted in jpg, gif, png, pdf, doc, docx, tif, ttf, txt formats.

Have you ever applied for assistance from CMN Hospitals before?
- Yes
- No
What kind of assistance are you requesting from CMN?
Ex: travel, hospital bills, therapy bills, prescriptions, etc.
Nature of child’s illness or injury
Name of child’s physicians

(Primary care or out of town)
Date(s) of hospitalization, if applicable
CoxHealth Account Number
(if hospital bills)
Do you have insurance?
- Yes
- No
What company?
Do you have Medicaid for your child?
- Yes
- No
- Denied
Do you have*
- MISSOURI
- ARKANSAS Medicaid
Have you applied for Medicaid?*
- Yes
- No
Do you pay a Medicaid premium*
- Yes
- No
Managed Care Plan?*
- No
- MoCare
- HomeStateHealth
- UHC
Medicaid #*
Why?

Father’s employer
Phone
Mother’s employer
Phone
If you are self-employed, please describe the nature of your business
Phone
Fathers Net Monthly Income $
Mother’s Net Monthly Income $
Child Support Received $
Other Business Income $
Income received from any other source (please explain) $

All assets should consist of an estimate of the value of property or vehicles owned. Please include estimates of current balances on investment or savings information.
Do you own your own home?
- Yes
- No
Approximate value of home $
How many vehicles do you own?
Value of vehicle #1 $
Value of vehicle #2 $
Total value of vehicles: $
Do you own farm equipment, jet skis, motorcycles, or any other recreational or other equipment?
- Yes
- No
Value of farm equipment: $
Value of other equipment: $
Retirement Funds/IRA/Pension:
- Yes
- No
Value of Retirement $
Pension $
Others $
Do you have money in investments such as stocks, CD’s, etc.
- Yes
- No
Value of Investments $
Do you own Rental Property?
- Yes
- No
Value of Property $
Monthly Income from Rental Property $
Do you own land/acreage?
- Yes
- No
Value of Land $
Number of acres
Do you own livestock?
- Yes
- No
Value of Livestock $
Type of Livestock
Cash on Hand $
Savings Account Balance $
Checking Account Balance $
Additional Assets:
Type: $
Type: $

MONTHLY EXPENSES — Please Estimate Monthly Payments
Rent/House Payment $
Child Care $
Vehicle Payment $
Gas for Vehicle(s) $
Food $
Child Support Paid $
Phone $
Utilities $
Insurance - Home $
If not included in mortgage.
Insurance - Auto $
Insurance - Life $
If not deducted from paycheck.
Insurance - Health $
If not deducted from paycheck.
Trash $
Business expenses $
Cable/Satellite Dish $
Other (please list) $
Internet $
Credit Card 1
Credit Card 1 - Type
Credit Card 1 - Monthly Payment $
Credit Card 1 - Balance $
Add 2nd credit card?
- Yes
- No
Credit Card 2
Credit Card 2 - Type
Credit Card 2 - Monthly Payment $
Credit Card 2 - Balance $
Add 3rd credit card?
- Yes
- No
Credit Card 3
Credit Card 3 - Type
Credit Card 3 - Monthly Payment $
Credit Card 3 - Balance $
Medical Expenses 1
Medical Expenses 1 - For
Medical Expenses 1 - Monthly Payment $
Medical Expenses 1 - Balance $
Add 2nd medical expenses?
- Yes
- No
Medical Expenses 2
Medical Expenses 2 - For
Medical Expenses 2 - Monthly Payment $
Medical Expenses 2 - Balance $
Add 3rd medical expenses?
- Yes
- No
Medical Expenses 3
Medical Expenses 3 - For
Medical Expenses 3 - Monthly Payment $
Medical Expenses 3 - Balance $
Student Loans
For
Balance $
Other Expenses (Please be Specific)
Finance Company
Monthly Payment $
Balance $
Children’s Miracle Network Hospitals is a charity designed to help families that have children age birth through 18 years of age with medical expenses not covered by insurance or Medicaid. Please list any additional information that would help us understand your needs.
ALL APPLICANTS PLEASE READ BELOW
I guarantee that the information in this request for funding is accurate, complete and true.
I understand that altering this application or providing false information in any way will result in denial of this request. I give Children’s Miracle Network Hospitals permission to contact any previous individuals and/or companies for references. I understand that a confirmation of my child’s need from a physician must accompany this application. I understand applications may take 5-7 business days to process, or up to 30 days for Family Care Grant requests (CoxHealth hospital & therapy bills).
I give my permission to CMN Hospitals to utilize my child’s story to support the mission and cause of CMNH through all forms/types of media not limited to include broadcast, print, electronic (i.e. social media) and radio.*
- Yes, I agree